1 - Hawaii Department of Health
|1. |Agency Referring to |
| |Name: | |
| |Address: | |Phone No.: | |
| | | | | | | |Fax No.: |
|2. |Service Referring to: | |
|3. |Referring Agency |
| |Name: | |
| |Address: | |Phone No.: | |
| | | | | |
|4. |Consumer Demographic Information |
| |Name: | |AMHD Ref. No.: | |
| |Gender: | Male |
| |Address: | |Home Ph. No.: | |
| |If homeless, | | | | | |Cell Ph. No.: |
| |indicate where | | | | | | |
| |the consumer can | | | | | | |
| |be found | | | | | | |
|5. |Legal Guardian (if applicable) |
| |Name: | |Relationship: | |
| |Address: | |Phone No.: | |
| | |
| |Axis I: | |
| |Axis II: | |
| |Axis III: | |
| |Axis IV: | |
| |Axis V: | |
|7. |Eligibility |
| |The consumer has been determined eligible for AMHD services: | Yes | No |
|8. |Forensics |
| |Legal Status: | Conditional Release | Other (specify): | |
| |Include a copy of the current conditional release or other current orders, if applicable. |
| |Court Date (if applicable): | | |
| |Forensic Coordinator Name: | |Phone No.: | |
| |Parole/Probation Officer Name: | |Phone No.: | |
|9. | Hospitalized Consumers (if applicable) |
| |Name of Hospital: | |
| |Discharge Meeting Date: | |Discharge Date: | |
|10. |Health Insurance |
| |Name of Health Insurance Company: | |Insurance Card No.: | |
| |(i.e., HMSA, Kaiser, etc.) |
|11. |Income |
| |Monthly Income: |$ | | |
| |Source of Income (i.e., work, SSI, SSDI, DHS, etc.): | |
| |Other Assets (i.e., savings, etc): | |
|12. |Psychiatrist |
| |Name: | |
| |Address: | |Phone No.: | |
| | |
| |Name: | |
| |Address: | |Phone No.: | |
| | |
| |Agency Name: | | |
| |CM/ACT Team Name: | |Phone No.: | |
| |CM/ACT Team Address: | |Fax No.: | |
| | |
| |Is housing needed? | Yes | No |
| |Does the consumer have a Sec. 8 rental subsidy? | Yes | No |
| |If referring for housing, indicate what level: | 24 Hour Group Home |
| |check only one (1) level | 8-16 Hour Group Home |
| | Semi-Independent Group Home |
| | Support Housing |
| | Shelter Plus Care |
| |If referring for housing, does the consumer require an accessible home or reasonable accommodation? | Yes | No |
| |If yes, please describe what the consumer needs: | |
| | |
| | |
|16. |Citizenship |
| |Citizenship Status: | US | Other (specify): | | | Unknown |
|17. |To be completed for referrals to the Kalihi Palama Community Fitness Restoration Program (KFIT) |
| |a. |Current legal charges: | |
| |b. |Legal Status (check the status that applies): | 704-404 |
| | | 704-406 |
| | | Other, specify: | |
| |c. |Order to Treat: | Yes | No |
| |d. |Advance MH Directive: | Yes | No |
| |e. |History of Violence: | Yes | No |
| | |If yes, date of last/most recent physically aggressive, assaultive behavior: | |
| | |If yes, date of last/most recent threatening behavior: | |
| |f. |Risk of Suicide: |Previous suicide attempt: | Yes | No |
| | |If yes, date of last/most recent suicide attempt: | |
| | |Suicidal ideation: | Yes | No |
| |g. |Elopement Risk: |Previous AWOL/AWA: | Yes | No |
| | |If yes, date of last/most recent episode of AWOL/AWA: | |
| |h. |Current or previous participation in fitness classes: | Yes | No |
|18. |Interpreter Services |
| |Does the consumer need an interpreter? | Yes | No |
| |If yes, what language: | | |
|19. |Rep Payee Services |
| |Does the consumer have a Rep Payee? | Yes | No |
| |If yes, name of Rep Payee: | |Phone No.: | |
|20. |Other Current Services |
| |Indicate any services the consumer is currently utilizing: | Peer Coach |
| | Respite |
| | CRF - amount owed: |$ | |
| | CBI (includes 1:1 wrap) |
| | Clubhouse |
| | DVR |
|21. |Please include the following documents: |
| |Consent to release information |
| |Master Recovery Plan (current) |
| |Most recent psychiatric evaluation with multiaxial diagnosis which is signed and dated |
| |Medical Problem List (include proof of PPD) |
| |Conditional Release or other Current Court Order (if applicable) |
| |HCR 20 (if applicable) |
| |Homeless certification (if referring for housing and if applicable) |
| |Copy of the order naming the guardian. (if #5 applies) |
|Complete #22 only if you are referring to a service listed in a, b, c, d or e below. If the service you are referring to is not listed in #22, go to #23. |
|22. |Please include the documents for the following services, if available. |
| |Please note: This is in addition to the documents required in #21 |
| |a. Specialized Residential Treatment, Day Treatment, Intensive Outpatient Hospital, E-ARCH: |
| |Nursing Assessment (most recent) |
| |Psychosocial Assessment |
| |Risk Assessment |
| |LOCUS (most recent) |
| |Psychological Testing |
| |Substance Abuse Assessment |
| |Medication Sheet |
| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunizations, PPD) |
| |Narrative update that includes presenting problem, precipitating events and justification for the service |
| |Special diet requirements |
| |Dental needs |
| |Required for referrals to Specialized Residential Treatment: What is the current discharge plan upon completion of the program. |
| |b. Hale Imua |
| |Nursing Assessment (most recent) |
| |Psychosocial Assessment |
| |Risk Assessment |
| |Psychological Testing |
| |Substance Abuse Assessment |
| |Medication Sheet |
| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunizations, PPD) |
| |Special diet requirements |
| |Dental needs |
| |LOCUS (most recent) |
| |c. KFIT |
| |Current psychiatric routine medications (name, strength/dosage, route, schedule) |
| |Current PRN medications. Include information on when the last PRN dosage was given. |
| |Add any medications being taken for medical problems listed on the medical problem list in #21. |
| |LOCUS (most recent) |
| |d. ACT, CBCM, and Outpatient Treatment |
| |Nursing Assessment (most recent) |
| |Psychosocial Assessment |
| |Risk Assessment |
| |LOCUS (most recent) |
| |Psychological Testing |
| |Substance Abuse Assessment |
| |Medication Sheet |
| |Medical History and Physical (most current) |
| |Dental needs |
| |e. PSR |
| |Nursing Assessment (most recent) |
| |Psychosocial Assessment |
| |Risk Assessment |
| |LOCUS (most recent) |
| |Substance Abuse Assessment |
| |Medication Sheet |
| |Medical History and Physical (completed within one year of referral date and includes Rubella Titer/proof of immunizations, PPD) |
| |Narrative update that includes presenting problem, precipitating events and justification for the service |
|23. |Referral Form completed by: | | |
| |Print Name | |
| | |Date: | |
| |Signature | |
| |
|PROVIDER DECISION FORM |
| To: | |From: | |
| |Referring Agency | |Provider and Type of Service |
| Consumer Name: | |
| | | | |
|DOB: | |AMHD Ref#: | |
| | | |
|Date Referral Received: | | |
|Date Decision Rendered: | Accepted | Denied |
|Service Referred to (POS Provider): | |
|If consumer was denied for this service, please complete the rest of this form |
|Current Diagnosis: |Axis I: | |
| |Axis II: | |
| |Axis III: | |
|Reason for Denial of Referral: |
| Consumer refused service |
| Does not meet criteria for this service (Please provide explanation): |
|Insufficient documentation, please provide the following information: |
| | |
| | |
| | |
| | |
| Consumer may be accepted in the future under the following circumstances: |
| | |
| | |
| | |
| | |
|It is recommended that this consumer pursue alternative placement/treatment with another provider or at another level such as: |
| | |
| | |
|Medical/Clinical Director Review: | | |
| |Print Name |Date: | |
| |Signature | |
|Administrative Executive Review: | | |
| |Print Name |Date: | |
| |Signature | |
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